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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELION tAVE., STOCKTON, CA Telephone (209) 486$781 PERMIT EXPIRES TYEAA FROM-DATE ISSUEDAppl ' (Complete in Tri licate) made lin on is hereby mach to the San Joaquin Local Health District for a permit to co r tr- ' ' made in compliance with San Joaquin County Ordinance No.549 for r2f, aM/or install the work Local Health District; swage or No. 1862 fo,well/pump and the Rqlas and p described.This application is . F,.,c, - , ,,,,. . Regulations of the San Joaquin Job Address 3434 . >: �. r GrH. 7 :.r . w - hi . aLuil. r � . ral •"J1 . f :4N A . . Ciry.y Lat Size %t. .. PM 1 ' Owner's Name Q LU - Address, y. _U)..7- .. ..�'�r w _ Lo. ..,� Phone -�=L �-. Contractor � � � ' � /�,/, � - Address �CZ`x f Phone" �F.��f. LYP.E.OF-WELL/PUMP:—�;---NEIN WAdd❑"'^y„--- License No. �.Z/ WEE17REPLA-CEMENT--o -----�DESTRUCTION--0—__-. PUMP INSTALLATION ❑ DISTANCE TO NEAREST:ySFPTIC TA F7K SYSTEM REPAIR ❑ OTHER ❑ SEWER LINES Y AOUNDA71ON DISPOSAL FLD. PROP. LINE —_ r AGRICULTURE WELL OTHER WELL INTENDED USE ✓ TYPE— pp yVEL PROBLEMAREA -CONSTRUCTION SPECIFICATIONS PITS/SUMPS — ❑ Industrial V C1 Open Bottom ❑Domestic/Private (h, ❑ Manteca Dia. of Well Excavation ' j ❑ Gravel Pafck ❑ Tracy' T Dia. of Well Casing "11 ❑ Public `0J ❑ Other # TYPO of Casing - .t I/ Specifications ❑ Irrigation a-fr .❑ Ieha Depth of Grout Seal ir,: 'L _APprox. Depth ❑ Eastern Surface Seal Installed by.:r 1— .•''�� Type of Grout /I•I Repair Work Oone ❑ Type of Pump _ .. Well Destrudtidn ❑ H.P. - r r „State-Work Dane yffff Well Diamefer Sealingems' d �../ Depth -.1 MatedaNtop EO') '=..I•`s S ddd p - Filler Material (Below 50') 1 TYPE OF•SEPTIC WORK: NEW INSTALLATION`Q REl: IZ:g ETM N ❑ 415- p/ �{ ! _ . S ETRUCTION ❑�lNo septic system permitted if public sewer is l- Inatellion will serve: Residence t — OtherI�� m ^s.•:aA aileble within Z00 fast.) s r Comrt+emial In wa.�•. _ Number of living units:_�- Number of bedrooms Character of soil to a depth of 3 feet SEPTIC TANK 1Q Type/Mfg" Water table depth PAG. TREATMENT PLT.❑ 9 ap ny-42-U�-_ No. Compartments i Method of Disposal Dis[ance.to nearest: Welb -° Foundation I--property Line >`IOGE r i I � LEACHING LINE - r x 9% No. R Length of lines — FILTER BED ❑ Distance to nearest; we SEEPAGE PITS ❑ '7 r -Total length/size f — Foundation-- ._�.Rr�mr�i'6�Une� ` Depth I pSize _ , SUMPS 1 >:.n r ❑ Distanceto neare9f: Well - --Number, ,1 tDISPOSAL PONDS ❑ ( Foundation .Property Line I hereby cattily that I have prepared this aPPlication and that the work will be done in accordance with San rHuulems saonwd nreegr uolratliicoenns soefd tahgeeSnta'sn sJigoanqatuuinre LceocrtailfieHseathlteh}DoXicotrwicintnv4,°.k.S'r..r-i+ � �'� ,,,,.( Joaquin county ordinances, state law , 1 and employ any person in such manner as to become subject to workman's compensation✓ pf Ca fi mien"'Conk for which hic th oPsutrco issued, I shall signature certifies the folbwi ng:"'I certify that in the pertarmance of the work fol which this permit is/ssuad,'I shall em toe tion laws of Cai'rfornia." p Y Persons subject to workman's co The applicant must call 11',py.�'rt;9'h'td.Q � mpensa nspectiens. Complete drawing on reverse side. - Oats: FOR D_EPART`MENT USE 0 LY ,l Application Accepted byc-' J_7 Pit or Grout Inapeetion by_--l �y'I_-, Date Area "ate `L -Final lnspection'by— Additional Comments: ate yl i ❑ Stk 466-6781 ".Lodi 369-36210 Manteca ^�--= �'••� n��''" + . eca Applicant- Return all copies 10: Em823.7104„vaacyp Tracy Environmental Health Permit/82X7104 1601.E..Huzelton;Ave., P!O.".Box 2009,Stk., CA 96201 INFO AMDUN7 DUE AMOUNT REMITTED CK EH 3.2r(REV 1iB61 CASH RECEIVED By DATE PERMIT'N0, F 1 . Cil f41e w